Covid-19 - Vulnerable Highest Risk Patients (Shielding)

People in the Clinically Extremely Vulnerable Group (CEV) 

From 5th January 2021, the Government has reintroduced shielding advice for Clinically Extremely Vulnerable (CEV) people across all areas of England. This shielding advice is expected to be identical to that which was in place nationally from 5 November to 2 December, and which was already in place in areas under Tier 4 restrictions. It is important to note that NHSE  PC Bulletin (6th Jan 21) advise that this advice does not alter if an individual has received the COVID-19 vaccination.

CEV people will be eligible for support to stay at home including free delivery of medicines (where friends, family, or local volunteers are unable to provide help) and statutory sick pay where unable to work from home.

The Government will be writing to all CEV individuals in England to inform them of the advice and support available (including individuals already advised to shield as part of Tier 4 restrictions). This letter will be published here and will emphasise the importance of CEV individuals continuing to engage with the NHS, and confirm that they will be prioritised for the COVID-19 vaccination in advance of the general population (as per current JCVI guidance). It is expected that Government will also be sending text messages and emails to affected patients where the NHS holds the relevant contact information.

 

Identifying the Clinically Extremely Vulnerable (CEV)

On 2nd November, NHSE & I sent an update on guidance for clinically extremely vulnerable individuals and actions for GPs.

Two additional groups of people have been identified who should now be considered as clinically extremely vulnerable to COVID-19: -

• adults with stage 5 chronic kidney disease 
• adults with Down’s syndrome 

These will be included along with the previous groups as below

• Solid organ transplant recipients.
• People with specific cancers:
• people with cancer who are undergoing active chemotherapy
• people with lung cancer who are undergoing radical radiotherapy
• people with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
• people having immunotherapy or other continuing antibody treatments for cancer
• people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
• people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
• People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary (COPD).
• People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), homozygous sickle cell).
• People on immunosuppression therapies sufficient to significantly increase risk of infection.
• Women who are pregnant with significant heart disease, congenital or acquired.

Practices are being asked to carry ouy the following specific actions: -

1. Familiarise yourself with the updated guidance for clinically extremely vulnerable people when it is published here. 

Publication will be communicated to all patients on the shielded patient list (SPL) by letters. These letters will provide evidence for Statutory Sick Pay purposes if required. NHSE will seek to provide primary care with any additional information following that publication here. 

2. Immediately review any children and young people remaining on the SPL who your practice added and, where appropriate, remove them from the SPL. Practices should also plan to urgently respond to calls from parents and guardians of children on the SPL seeking a review – parents and guardians will be advised by Government to contact their child’s specialist or their GP, if they are still unsure whether their child should remain on the SPL (Annex 1).

a. NHSE want to highlight that the vast majority of children and young people who have been reviewed to date using the Royal College of Paediatrics and Child Health ( RCPCH ) guidance have been found to be no longer considered clinically extremely vulnerable. Given the detrimental impact to children’s wellbeing of following unnecessary additional restrictions, it is important we complete this exercise as soon as possible.

3. Urgently identify, contact and flag adults with Down’s syndrome. You may also want to take the opportunity to ensure they receive a flu vaccine and to schedule an annual health check if these are needed (Annex 2). Practices are asked to

• Run a search on in systems for adults (18 and over) with Down’s syndrome. Details and the relevant codes to use will be on the NHS Digital website. Please note, in contrast to previous additions to the SPL, at this stage there will not be a central process to identify these patients.
• Contact the patients
• Provide the patient letters: A specific new ‘patient additions’ letter for this cohort has been created for this purpose, which should be avaialble shortly and will also be available in Easy Read. NHSE recommend that both the Easy Read and the full patient letter are provided. If possible, a colour edition of the Easy Read version should be provided. The letters will be available for download from the NHS Digital website.  NHSE also advise that they will also shortly be available in your system template libraries.
• Patients and their families/carers can also be referred to the Down’s syndrome Association website and helpline – 0333 12 12 300 – for further accessible resources and other types of information and support.

4. Flag the patient record: with the ‘high-risk from developing complications from coronavirus’ flag to add them to the SPL. Details of how to do this are on the NHS Digital website.

 

People with stage 5 chronic kidney disease

• At this time there is no action required from practices regarding identification of these patients. However, NHSE recognise that practices may be approached by patients hearing of the inclusion of stage 5 chronic kidney disease. These patients should be advised that they will be contacted by their renal unit.

• If, after discussion, the practice wishes to add the patient themselves, this can be done by applying the high risk marker to their record. Please ensure that you also send them the appropriate patient letter and notify their renal unit of their inclusion. These letters will shortly be available in your system template libraries and on the NHS Digital website.

 

4. Ensure you continue to maintain the SPL by adding a high risk flag for patients you identify as being clinically extremely vulnerable, and notifying the patient of their status and the advice they should follow. Information on maintaining the SPL can be found on the NHS Digital website. NHSE have previously published best practice guidance on providing NHS care for those who shielded during the initial wave of COVID (see Annex B in 4 June letter ).

 

Support will remain available to the CEV group from NHS volunteers and practices can make a referral at  https://www.goodsamapp.org/NHSreferral

Children

16^th Nov 2020 – NHSE have produced a document entitled Reviewing and removing children and young people from the Shielded Patient List Instructions for clinicians and data leads. This is to aid conversations and the decision processes and has guidance specific for GP’s on Pages 7 & 8. Click on the image to download your copy.

Further guidance was published in 8th July confirming that the majority currently considered extremely vulnerable to Covid-19 would be able to be removed from the shielded patient list. The guidance can be viewed here .

Adults with Downs Syndrome have been added to the Clicically extremely vulnerable list, however, the RCGP have made the following staement about children with Down's Syndrome

There is evidence that some adults with Down’s syndrome may be at risk of complications from COVI-19, this primarily appears to be age related. There is no evidence that children with Downs syndrome and without co-morbidities need to take more care than is currently advised for all. Some children with Downs syndrome will have co-morbidities from either Group A or Group B, and they and their families will need to have conversations with their clinicians to determine if they are clinically extremely vulnerable. More information is available from the  Down’s Syndrome Association. 

The Royal College of Paediatrics and Child Health

Covid-19 – shielding advice for children and young people

Summary

The RCPH has updated its advice for clinicians on which paediatric patient groups should be advised to 'shield' during the COVID-19 outbreak, to protect those at very high risk of severe illness from coming into contact with the virus. It also provides frequently asked questions on how 'shielding' applies to children and families. We would recommend that you refer to the detailed guidance for comprehensive advice, however, the following provides a summary of some of the key points.

In updating their advice, the RCPH has conducted a review of the evidence which has indicated that not all those children and young people who are currently advised to shield need to continue to do so. The majority of children with conditions including asthma, diabetes, epilepsy, and kidney disease do not need to continue to shield and can, for example, return to school as they reopen. This includes many children with conditions such as cerebral palsy and scoliosis, for whom the benefits of school - in terms of access to therapies and developmental support - far outweigh the risk of infection.

In principle:

• Children and young people who are cared for just in primary care are very unlikely to need to continue to shield.
• A small group of children who are ‘clinically extremely vulnerable’ due to their pre-existing condition will need to continue to shield.
• A further larger group of children exists who due to their underlying condition may need to shield and the decision to continue to shield would normally result from a discussion between the clinician, the child and their family

In the document, conditions are divided into two groups, as follows:

• Group A lists conditions that require continued shielding. A child with a condition in Group A should be advised to shield.
• Group B lists conditions that require discussion between the clinician and the child and their family/carer to establish whether on a case by case basis continued shielding is required. A child in Group B should have a discussion with their clinical team to establish whether on balance of risks they should be advised to shield. Not all children and young people with conditions listed in Group B will need to shield. If following a discussion, they are advised not to shield, the child should maintain stringent social distancing.

Group A includes:

• Immunodeficiency and immunosuppression
• Oncology

Group B includes:

Conditions listed in the categories below will require a case-by-case discussion to decide whether, on the balance of risks, a child should be advised to continue shield. Not all children and young people in the categories listed below will need to shield.

A decision to shield will depend on the severity of the condition and knowledge that the secondary and tertiary care clinical teams have of the particular circumstances of the child. If following a discussion, a child is advised not to shield, they should maintain stringent social distancing.

• Cardiology
• Dermatology
• Haematology
• Immunodeficiency
• Neonatal
• Neurology
• Paediatric Gastroenterology, Hepatology & Nutrition
• Respiratory
• Renal
• Rheumatology / Paediatric ophthalmology

Children who are shielded should still attend hospital for essential treatment as recommended by their clinical teams, following risk assessment.

The RCPH advice reflects the current understanding of the risks associated with COVID-19 infection. Their advice will continue to be updated and revised more is understood about the impact of COVID-19 infection on the health of children and young people with comorbidities. It is therefore important to refer to the full guidance at https://www.rcpch.ac.uk/resources/covid-19-shielding-guidance-children-young-people#introduction .